1
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Ruwanpathirana P, Chang T. Uraemic brainstem encephalopathy mimicking ocular myasthenia: a case report. BMC Neurol 2024; 24:121. [PMID: 38609854 PMCID: PMC11010437 DOI: 10.1186/s12883-024-03626-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Uraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy. CASE PRESENTATION A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain. CONCLUSIONS Uraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia.
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Affiliation(s)
- Pramith Ruwanpathirana
- Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, 01000, Sri Lanka.
| | - Thashi Chang
- Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, 01000, Sri Lanka
- Department of Clinical Medicine, University of Colombo, 25, Kynsey Road, Colombo, 00800, Sri Lanka
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2
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Nikoghosyan A, Lambert J. Low Consciousness in a Patient with Pancolitis. J Belg Soc Radiol 2024; 108:17. [PMID: 38371363 PMCID: PMC10870939 DOI: 10.5334/jbsr.3265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/16/2024] [Indexed: 02/20/2024] Open
Abstract
Teaching point: Lentiform fork sign is a rare finding on MRI of the brain, found in patients with metabolic acidosis, in a critically ill patient with low consciousness and renal failure, this sign can correspond to uremic encephalopathy.
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Affiliation(s)
- Ani Nikoghosyan
- Department Radiology, UZ Leuven, campus Gasthuisberg, Leuven, Belgium Herestraat 49/B, 3000 Leuven
| | - Julie Lambert
- Department Radiology, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium Herestraat 49/B, 3000 Leuven
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3
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Ahmed A, Patel B, Wang R, Luna L, Verde A, Besheli LD, Intrapiromkul J, Nabi M, Edpuganti N, Deng F, Yedavalli V. Clinical applications of arterial spin labeling of the intracranial compartment in vascular anomalies-A case-based review. Neuroradiol J 2023; 36:638-650. [PMID: 36172883 PMCID: PMC10649537 DOI: 10.1177/19714009221130490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arterial spin labeling (ASL) is a magnetic resonance perfusion technique that allows for quantification of cerebral blood flow (CBF) without the use of contrast or radiation. Several applications of ASL have been described in diagnosis of strokes and stroke mimics, intracranial tumors, and other conditions. Various vascular anomalies exhibit specific CBF patterns that correlate with different signal intensities on ASL. In this case-based review, we demonstrate the utility of ASL in diagnosis and surveillance of vascular anomalies in the intracranial compartment.
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Affiliation(s)
- Amara Ahmed
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Bhumi Patel
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Laleh Daftari Besheli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jarunee Intrapiromkul
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Namratha Edpuganti
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Francis Deng
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
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4
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Jones JA, Cason RK, Chambers ET, Pizoli CE, Kumar KR. Aphasia Associated With Acute on Chronic Kidney Failure in an Adolescent. Cureus 2023; 15:e49044. [PMID: 38116335 PMCID: PMC10728582 DOI: 10.7759/cureus.49044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/21/2023] Open
Abstract
Acute and chronic kidney disease (CKD) have known neurological associations resulting from uremia, electrolyte disturbances, comorbidities such as hypertension, or other toxin accumulation. Reversible focal neurological deficits are relatively uncommon and poorly understood sequelae of kidney disease. Herein, we describe an unusual case of an adolescent male who developed acute aphasia during his initial presentation for acute kidney injury (AKI) superimposed on progressive CKD stage 5 associated with uremia and multiple electrolyte derangements. Symptoms resolved within one day of initiating continuous renal replacement therapy (CRRT) and gradual electrolyte and uremia correction. Such transient focal neurological deficits in AKI superimposed on progressive CKD in the pediatric population has not been widely reported.
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Affiliation(s)
- Jacqueline A Jones
- Department of Pediatrics, Duke University School of Medicine, Durham, USA
| | - Rachel K Cason
- Department of Pediatrics, Duke University School of Medicine, Durham, USA
| | - Eileen T Chambers
- Department of Pediatrics, Duke University School of Medicine, Durham, USA
| | - Carolyn E Pizoli
- Department of Pediatrics, Duke University School of Medicine, Durham, USA
| | - Karan R Kumar
- Department of Pediatrics, Duke University School of Medicine, Durham, USA
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5
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Alhusseini A, Hamsho S, Alabdullah H, Alaswad M, Sleiay M, Alsamarrai O. Uremic encephalopathy manifesting with a unique MRI finding (the lentiform fork sign) in an adult male: A case report. Clin Case Rep 2023; 11:e8233. [PMID: 38028094 PMCID: PMC10661331 DOI: 10.1002/ccr3.8233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023] Open
Abstract
A novel radiologic sign in patients with renal failure and uremic encephalopathy (UE) with metabolic acidosis has recently been identified as the lentiform fork sign. On magnetic resonance imaging (MRI), the "lentiform fork sign" has been described as bilateral symmetrical hyperintensities in the basal ganglia encircled by a hyperintese rim delineating the lentiform nucleus. Changes in uremic solute retention, aberrant blood-brain barrier transport, disordered vascular reactivity, altered electrolyte and acid-base balance, and altered hormone metabolism are the most likely causes of the condition. A 56-year-old male with end-stage renal disease was brought to the emergency room for a progressive change in mental status and involuntary arm movements over the previous 5 days, which were accompanied by mild dyspnea. A brain MRI was performed, and it revealed hyperintensity on T2/FLAIR in the white matter surrounding the basal ganglia. the patient was treated with dialysis and improved greatly. Intensified hemodialysis and glycemic control are the cornerstones of treating diabetic uremic syndrome (DUS) with likely reversible clinical symptoms and remission of imaging abnormalities.
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Affiliation(s)
- Ayham Alhusseini
- Neurology Department, Faculty of MedicineDamascus UniversityDamascusSyria
| | - Suaad Hamsho
- Rheumatology Department, Faculty of medicineDamascus UniversityDamascusSyria
| | | | | | | | - Omar Alsamarrai
- Neurology Department, Faculty of MedicineDamascus UniversityDamascusSyria
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6
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Philbert SA, Xu J, Scholefield M, Patassini S, Church SJ, Unwin RD, Roncaroli F, Cooper GJS. Extensive multiregional urea elevations in a case-control study of vascular dementia point toward a novel shared mechanism of disease amongst the age-related dementias. Front Mol Neurosci 2023; 16:1215637. [PMID: 37520429 PMCID: PMC10372345 DOI: 10.3389/fnmol.2023.1215637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Vascular dementia (VaD) is one of the most common causes of dementia among the elderly. Despite this, the molecular basis of VaD remains poorly characterized when compared to other age-related dementias. Pervasive cerebral elevations of urea have recently been reported in several dementias; however, a similar analysis was not yet available for VaD. Methods Here, we utilized ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) to measure urea levels from seven brain regions in post-mortem tissue from cases of VaD (n = 10) and controls (n = 8/9). Brain-urea measurements from our previous investigations of several dementias were also used to generate comparisons with VaD. Results Elevated urea levels ranging from 2.2- to 2.4-fold-change in VaD cases were identified in six out of the seven regions analysed, which are similar in magnitude to those observed in uremic encephalopathy. Fold-elevation of urea was highest in the basal ganglia and hippocampus (2.4-fold-change), consistent with the observation that these regions are severely affected in VaD. Discussion Taken together, these data not only describe a multiregional elevation of brain-urea levels in VaD but also imply the existence of a common urea-mediated disease mechanism that is now known to be present in at least four of the main age-related dementias.
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Affiliation(s)
- Sasha A. Philbert
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jingshu Xu
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Melissa Scholefield
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Stefano Patassini
- Faculty of Science, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - Stephanie J. Church
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Richard D. Unwin
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Federico Roncaroli
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biology, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, United Kingdom
| | - Garth J. S. Cooper
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Advanced Discovery and Experimental Therapeutics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Faculty of Science, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
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7
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Arora N, Mehdi Z, D’Cruz S, Sharma I. Orofacial Dyskinesia in Uremia in Polycystic Kidney Disease. J Emerg Trauma Shock 2023; 16:130-132. [PMID: 38025501 PMCID: PMC10661570 DOI: 10.4103/jets.jets_8_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 12/01/2023] Open
Abstract
Uremic encephalopathy presenting as involuntary movements of the orofacial region is important to recognize because of reversibility seen with resolution of azotaemia though residual neurological dysfunction might persist. Neuroimaging is important part of diagnosis with typical lesions involving basal ganglia seen mostly in diabetic patients. Our case highlights a patient with non-diabetic uremic encephalopathy with facial dyskinesia which is rare with a lesion in unilateral lentiform nucleus and small white matter hyperintensities. Resolution following dialysis pointed to uraemia as aetiology.
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Affiliation(s)
- Nidhi Arora
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Zainab Mehdi
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Sanjay D’Cruz
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Isha Sharma
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
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8
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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9
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Clingan MJ, Zhang Z, Caserta MP, Cox KL, Gupta V, Baumgarten DA, Zhai QJ, Alexander LF. Imaging Patients with Kidney Failure. Radiographics 2023; 43:e220116. [PMID: 37053100 DOI: 10.1148/rg.220116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
The approach to imaging a patient with kidney failure continues to evolve. Overstatement of the risk of iodinated contrast material-induced (ie, contrast-induced) acute kidney injury and new guidelines for administration of gadolinium-based contrast media affect screening and the choice of contrast material. Treatment of kidney failure requires dialysis or a kidney transplant. Pretransplant imaging includes assessment for the feasibility of performing a transplant and evaluation for underlying malignancy and peripheral vascular disease. Patients with kidney failure are at high risk for renal cell carcinoma. Subtypes that occur exclusively or more commonly in patients with kidney failure, such as acquired cystic kidney disease, renal cell carcinoma, and clear cell papillary renal cell carcinoma, have specific clinical-pathologic characteristics, with indolent behavior. Performing US for dialysis planning increases the success of placement of an arteriovenous fistula, while postoperative US evaluation is essential in assessment of access dysfunction. Systemic manifestations in patients with kidney failure are multifactorial and may relate to the underlying cause of renal failure or may be secondary to treatment effects. Disturbances in mineral and bone metabolism and soft-tissue and vascular calcifications are seen in patients with chronic kidney disease and mineral bone disorder. Neurologic and cardiothoracic complications are also common. The authors provide a comprehensive overview of imaging considerations for patients with kidney failure, including the appropriate use of CT, MRI, and US with their respective contrast agents; the use of imaging in transplant workup and dialysis assessment; and the common renal and extrarenal manifestations of kidney failure. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Mary Jennings Clingan
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Zhao Zhang
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Melanie P Caserta
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Kelly L Cox
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Vivek Gupta
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Deborah A Baumgarten
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Qihui Jim Zhai
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Lauren F Alexander
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
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10
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Conroy AL, Datta D, Hoffmann A, Wassmer SC. The kidney-brain pathogenic axis in severe falciparum malaria. Trends Parasitol 2023; 39:191-199. [PMID: 36737313 PMCID: PMC11071448 DOI: 10.1016/j.pt.2023.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 02/05/2023]
Abstract
Severe falciparum malaria is a medical emergency and a leading cause of death and neurodisability in endemic areas. Common complications include acute kidney injury (AKI) and cerebral malaria, and recent studies have suggested links between kidney and brain dysfunction in Plasmodium falciparum infection. Here, we review these new findings and present the hypothesis of a pivotal pathogenic crosstalk between the kidneys and the brain in severe falciparum malaria. We highlight the evidence of a role for distant organ involvement in the development of cerebral malaria and subsequent neurocognitive impairment post-recovery, describe the challenges associated with current diagnostic shortcomings for both AKI and brain involvement in severe falciparum malaria, and explore novel potential therapeutic strategies.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Dibyadyuti Datta
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Angelika Hoffmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Samuel C Wassmer
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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11
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Imaging of metabolic and overload disorders in tissues and organs. Jpn J Radiol 2023; 41:571-595. [PMID: 36680702 DOI: 10.1007/s11604-022-01379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/24/2022] [Indexed: 01/22/2023]
Abstract
Metabolic and overload disorders are a heterogeneous group of relatively uncommon but important diseases. While imaging plays a key role in the early detection and accurate diagnosis in specific organs with a pivotal role in several metabolic pathways, most of these diseases affect different tissues as part of a systemic syndromes. Moreover, since the symptoms are often vague and phenotypes similar, imaging alterations can present as incidental findings, which must be recognized and interpreted in the light of further biochemical and histological investigations. Among imaging modalities, MRI allows, thanks to its multiparametric properties, to obtain numerous information on tissue composition, but many metabolic and accumulation alterations require a multimodal evaluation, possibly using advanced imaging techniques and sequences, not only for the detection but also for accurate characterization and quantification. The purpose of this review is to describe the different alterations resulting from metabolic and overload pathologies in organs and tissues throughout the body, with particular reference to imaging findings.
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12
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Lizarazo DA, Lizarazo J. Uremic Encephalopathy. Radiology 2022; 307:e221602. [PMID: 36537897 DOI: 10.1148/radiol.221602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- David A. Lizarazo
- From the Department of Diagnostic Imaging, Fundación Santa Fe de Bogotá, Universidad El Bosque, Ave 116 No. 9-02, Bogotá 110246, Colombia (D.A.L.); and Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Universidad de Pamplona, Cúcuta, Colombia (J.L.)
| | - Jairo Lizarazo
- From the Department of Diagnostic Imaging, Fundación Santa Fe de Bogotá, Universidad El Bosque, Ave 116 No. 9-02, Bogotá 110246, Colombia (D.A.L.); and Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Universidad de Pamplona, Cúcuta, Colombia (J.L.)
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13
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Wijdicks EFM. Identifying encephalopathies from acute metabolic derangements. J Intern Med 2022; 292:846-857. [PMID: 35809045 DOI: 10.1111/joim.13538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Metabolic derangements, when acute and severe, affect brain function. This presents mostly with a marked decline in the level of consciousness, resulting in impaired responsiveness, abnormal receptivity, impaired content, and loss of memory retention. The term metabolic encephalopathy has been used but is conjecture that can be challenged in the age of modern neuroimaging. We now recognize that many metabolic encephalopathies may involve structural lesions and at an early stage. Common clinical conundrums are the evaluation of the degree of brain injury and its recoverability. This review discusses the appropriate terminology for these conditions, the diagnostic approach, therapy recommendations, and prediction of recovery potential. In evaluating a presumed metabolic cause for encephalopathy, we must (1) search for and rule out structural injury to the brain despite an obvious explanatory metabolic derangement, (2) recognize that several confounding conditions often co-exist, and (3) acknowledge that resolution of brain dysfunction may be protracted despite normalization of laboratory values.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Sakurai K, Ikenouchi H, Yamamoto N, Furuta K, Ogawa R, Endo K. Uremic Encephalopathy Presenting with Unilateral Destructive Leukoencephalopathy Successfully Treated with Hemodialysis. Intern Med 2022; 62:1351-1353. [PMID: 36198609 DOI: 10.2169/internalmedicine.9494-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
An 81-year-old woman was hospitalized with progressive consciousness disturbance. Blood tests showed acidemia with severe renal dysfunction, and a cerebral spinal fluid (CSF) test showed pleocytosis with myelin basic protein (MBP) elevation. Brain magnetic resonance imaging showed unilaterally dominant subcortical white matter lesions with lentiform fork sign on T2-weighted imaging. After initiating hemodialysis, her consciousness disturbance and white matter lesions improved, suggesting uremic encephalopathy (UE). Unilaterally dominant leukoencephalopathy and high pleocytosis with MBP elevation in CSF are less common than previously identified characteristics of UE. When unilateral leukoencephalopathy occurs in patients with renal failure, UE should be considered.
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Affiliation(s)
| | | | | | - Kyohei Furuta
- Division of Internal Medicine, Sendai City Hospital, Japan
| | - Ryo Ogawa
- Division of Neurology, Sendai City Hospital, Japan
| | - Kaoru Endo
- Division of Neurology, Sendai City Hospital, Japan
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15
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Varughese RT, Shah YD, Johnson AA, Kothare SV. Atypical Imaging Presentation of Neonatal Uremic Encephalopathy. Neurol India 2022; 70:2315-2316. [PMID: 36352695 DOI: 10.4103/0028-3886.359192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robin T Varughese
- Department of Pediatric Neurology, Cohen Children's Hospital and Medical Center, Long Island Jewish Medical Center, Glen Oaks, NY, USA
| | - Yash D Shah
- Department of Pediatric Neurology, Cohen Children's Hospital and Medical Center, Long Island Jewish Medical Center, Glen Oaks, NY, USA
| | - Alan A Johnson
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell and North Shore University Hospital, Manhasset, NY, USA
| | - Sanjeev V Kothare
- Department of Pediatric Neurology, Cohen Children's Hospital and Medical Center, Long Island Jewish Medical Center, Glen Oaks, NY, USA
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16
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Sina F, Najafi D, Aziz-Ahari A, Shahraki E, Ahimahalle TZ, Namjoo Z, Hassanzadeh S. Uremic encephalopathy: A definite diagnosis by magnetic resonance imaging? Eur J Transl Myol 2022; 32. [PMID: 36036353 PMCID: PMC9580542 DOI: 10.4081/ejtm.2022.10613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/18/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate the magnetic resonance imaging (MRI) findings for the diagnose uremic encephalopathy and describe the usefulness of MRI findings in the ultimate diagnosis of uremic encephalopathy (UE). A total of 20 patients with uremic encephalopathy admitted to the hospital were evaluated in this prospective study. The clinical manifestations, laboratory and MRI imaging findings, demographic information, and clinical outcome were analyzed for each patient. We observed that the 20 prospectively reviewed patients with UE had no involvement of the basal ganglia or the lentiform fork sign (LFS). However, two-thirds of the patients had white matter involvement, and 80% of the subjects had cerebral or cortical atrophy. The arterial blood gas (ABG) analysis revealed that 50% of the patients suffered from metabolic acidosis (n=10). The results of the present study demonstrated that although the observation of Lentiform Fork Sign and Basal Ganglia involvement in MRI of UE patients is a specific finding the absence of which does not rule out UE. Thus, simultaneous examination of clinical manifestation and laboratory test analyses, along with imaging findings, should also be taken into account.
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Manickavasagar R, Chemmanam T, Youssef A, Agarwal A, Prentice DA, Irish AB. The extrapyramidal syndromes of chronic kidney disease and dialysis (EPS-CKDD): diagnostic criteria, risk factors and prognosis. QJM 2022; 115:359-366. [PMID: 34010386 DOI: 10.1093/qjmed/hcab140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/04/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acute extrapyramidal movement disorders in dialysis patients are rare, inconsistently defined and have uncertain aetiology and prognosis. AIM Define diagnostic criteria, prognosis and risk factors. DESIGN AND METHODS Retrospective case series review of 20 patients (14 female, mean age 62 years) receiving dialysis for a median of 15 (interquartile range 4-35) months who presented with acute parkinsonism (AP = 11) or chorea/athetosis (CA = 9). RESULTS All patients had type 2 diabetes (HbA1c 6.8 ± 1.0) and had received metformin. Lactic acidosis was present in 2 patients at presentation and serum lactate was elevated in 7/15 patients tested. No patient had abnormal copper or thyroid metabolism and 5/8 patients tested returned marginal abnormalities in heavy metal screening. Magnetic resonance imaging (MRI) revealed characteristic bilateral symmetric T2 hyperintensity of the basal ganglia (BG), predominantly putamen and globus pallidus (the lentiform nucleus) and more extensive involvement of the external and internal capsules in patients with AP presentation. Post-mortem demonstrated cytotoxic necrosis of the BG. Therapy included thiamine, intensive dialysis and cessation of metformin. Two patients died acutely, nine recovered and nine had residual symptoms. Median survival did not differ by presentation: AP 24 [95% confidence interval (CI) 21-27] and CA 33 (95% CI 32-35) months, P = 0.21. CONCLUSIONS There are two distinct clinical extrapyramidal movement disorders associated with specific diagnostic MRI imaging that support the diagnosis of the extrapyramidal syndromes of chronic kidney disease and dialysis. The associations with diabetes, metformin and metabolic acidosis suggest a common pathogenic mechanism but require additional study. Early recognition and treatment may improve outcomes.
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Affiliation(s)
- R Manickavasagar
- Department of Nephrology and Transplantation, Fiona Stanley Hospital, 11-15 Robin Warren Drive, Murdoch, WA 6150, Australia
| | - T Chemmanam
- Department of Neurology, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, Perth, WA 6009, Australia
| | - A Youssef
- Neurological Intervention and Imaging Service, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - A Agarwal
- Neurological Intervention and Imaging Service, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - D A Prentice
- Perron Institute for Neurological and Translational Science, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - A B Irish
- Department of Nephrology and Transplantation, Fiona Stanley Hospital, 11-15 Robin Warren Drive, Murdoch, WA 6150, Australia
- Faculty of Medicine and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA 6009, Australia
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18
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Olsen E, van Galen G. Chronic Renal Failure-Causes, Clinical Findings, Treatments and Prognosis. Vet Clin North Am Equine Pract 2022; 38:25-46. [DOI: 10.1016/j.cveq.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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19
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Steinbach EJ, Harshman LA. Impact of Chronic Kidney Disease on Brain Structure and Function. Front Neurol 2022; 13:797503. [PMID: 35280279 PMCID: PMC8913932 DOI: 10.3389/fneur.2022.797503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/24/2022] [Indexed: 12/29/2022] Open
Abstract
Chronic kidney disease (CKD) affects more than 37 million American adults. Adult-onset CKD is typically attributed to acquired comorbidities such as aging, type II diabetes, and cardiovascular disease. Conversely, congenital abnormalities of the kidney and urinary tract are the most common cause of CKD in children. Both adult and pediatric patients with CKD are at risk for neurocognitive dysfunction, particularly in the domain of executive function. The exact mechanism for neurocognitive dysfunction in CKD is not known; however, it is conceivable that the multisystemic effects of CKD—including hypertension, acidosis, anemia, proteinuria, and uremic milieu—exert a detrimental effect on the brain. Quantitative neuroimaging modalities, such as magnetic resonance imaging (MRI), provide a non-invasive way to understand the neurobiological underpinnings of cognitive dysfunction in CKD. Adult patients with CKD show differences in brain structure; however, much less is known about the impact of CKD on neurodevelopment in pediatric patients. Herein, this review will summarize current evidence of the impact of CKD on brain structure and function and will identify the critical areas for future research that are needed to better understand the modifiable risk factors for abnormal brain structure and function across both pediatric and adult CKD populations.
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Affiliation(s)
- Emily J. Steinbach
- Department of Radiation Oncology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Lyndsay A. Harshman
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, United States
- *Correspondence: Lyndsay A. Harshman
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20
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2021; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/20/2022] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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21
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Crowe K, Quinn TJ, Mark PB, Findlay MD. "Is It Removed During Dialysis?"-Cognitive Dysfunction in Advanced Kidney Failure-A Review Article. Front Neurol 2021; 12:787370. [PMID: 34925220 PMCID: PMC8674209 DOI: 10.3389/fneur.2021.787370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Cognitive impairment is independently associated with kidney disease and increases in prevalence with declining kidney function. At the stage where kidney replacement therapy is required, with dialysis or transplantation, cognitive impairment is up to three times more common, and can present at a younger age. This is not a new phenomenon. The cognitive interactions of kidney disease are long recognized from historical accounts of uremic encephalopathy and so-called "dialysis dementia" to the more recent recognition of cognitive impairment in those undergoing kidney replacement therapy (KRT). The understanding of cognitive impairment as an extra-renal complication of kidney failure and effect of its treatments is a rapidly developing area of renal medicine. Multiple proposed mechanisms contribute to this burden. Advanced vascular aging, significant multi-morbidity, mood disorders, and sleep dysregulation are common in addition to the disease-specific effects of uremic toxins, chronic inflammation, and the effect of dialysis itself. The impact of cognitive impairment on people living with kidney disease is vast ranging from increased hospitalization and mortality to decreased quality of life and altered decision making. Assessment of cognition in patients attending for renal care could have benefits. However, in the context of a busy clinical service, a pragmatic approach to assessing cognitive function is necessary and requires consideration of the purpose of testing and resources available. Limited evidence exists to support treatments to mitigate the degree of cognitive impairment observed, but promising interventions include physical or cognitive exercise, alteration to the dialysis treatment and kidney transplantation. In this review we present the history of cognitive impairment in those with kidney failure, and the current understanding of the mechanisms, effects, and implications of impaired cognition. We provide a practical approach to clinical assessment and discuss evidence-supported treatments and future directions in this ever-expanding area which is pivotal to our patients' quality and quantity of life.
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Affiliation(s)
- Kirsty Crowe
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B. Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark D. Findlay
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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22
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Suzuki R, Sato M, Ogura M, Murofushi Y, Abe Y, Kamei K. Unilateral motor weakness with kidney failure: Answers. Pediatr Nephrol 2021; 36:4131-4134. [PMID: 34499255 DOI: 10.1007/s00467-021-05187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ryutaro Suzuki
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yuka Murofushi
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuichi Abe
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
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23
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Abstract
Uremic encephalopathy encompasses a wide range of central nervous system abnormalities associated with poor kidney function occurring with either progressive chronic kidney disease or acute kidney injury. The syndrome is likely caused by retention of uremic solutes, alterations in hormonal metabolism, changes in electrolyte and acid-base homeostasis, as well as changes in vascular reactivity, blood-brain barrier transport, and inflammation. There are no defining clinical, laboratory, or imaging findings, and the diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation. The diagnosis is also made difficult because of the many confounding and overlapping conditions seen in patients with chronic kidney disease and acute kidney injury. Thus, institution of kidney replacement therapy should be considered as a trial to improve symptoms in the right clinical context. Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations. Further knowledge linking possible uremic retention solutes with neurological symptoms is needed to better understand this syndrome as well as to develop more tailored treatments that aim to improve cognitive function.
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24
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Clinical applications of diffusion-weighted sequence in brain imaging: beyond stroke. Neuroradiology 2021; 64:15-30. [PMID: 34596716 PMCID: PMC8484843 DOI: 10.1007/s00234-021-02819-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/10/2021] [Indexed: 11/20/2022]
Abstract
Diffusion-weighted imaging (DWI) is a well-established MRI sequence for diagnosing early stroke and provides therapeutic implications. However, DWI yields pertinent information in various other brain pathologies and helps establish a specific diagnosis and management of other central nervous system disorders. Some of these conditions can present with acute changes in neurological status and mimic stroke. This review will focus briefly on diffusion imaging techniques, followed by a more comprehensive description of the utility of DWI in common neurological entities beyond stroke.
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25
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Narra RK. Lentiform fork sign in uraemic encephalopathy. BMJ Case Rep 2021; 14:e245623. [PMID: 34535496 PMCID: PMC8451301 DOI: 10.1136/bcr-2021-245623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rama Krishna Narra
- Radiodiagnosis, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India
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26
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Forbes E, Vaswani PA, Duda JE, Morley JF. Uremic Striatopallidal Syndrome Manifesting as Acute Onset Chorea. Mov Disord Clin Pract 2021; 8:S55-S57. [PMID: 34514054 DOI: 10.1002/mdc3.13285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Emily Forbes
- Parkinson's Disease Research, Education and Clinical Center Michael J. Crescenz Veterans Affairs Medical Center Philadelphia Pennsylvania USA.,Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA.,Department of Neurology, School of Medicine University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - Pavan A Vaswani
- Parkinson's Disease Research, Education and Clinical Center Michael J. Crescenz Veterans Affairs Medical Center Philadelphia Pennsylvania USA.,Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - John E Duda
- Parkinson's Disease Research, Education and Clinical Center Michael J. Crescenz Veterans Affairs Medical Center Philadelphia Pennsylvania USA.,Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - James F Morley
- Parkinson's Disease Research, Education and Clinical Center Michael J. Crescenz Veterans Affairs Medical Center Philadelphia Pennsylvania USA.,Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
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27
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Chotai AA, Mitra D. Case report: MRI findings of acute uremic encephalopathy in a 1-year-old boy. BJR Case Rep 2021; 7:20210057. [PMID: 35136629 PMCID: PMC8803235 DOI: 10.1259/bjrcr.20210057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 11/11/2022] Open
Abstract
We present a 1-year-old boy who presented to the emergency department with a 7-day history of diarrhoea and vomiting. The initial renal function profile demonstrated a urea of 55 mmol l−1 (normal range between 5 and 20 mmol l−1), creatinine 695 micromol/L (normal range between 62–106 micromol/L) and potassium 9.1 mmol l−1 (normal range between 3.5–5.0 mmol l−1), with a profound metabolic acidosis. Upon examination, there were no significant findings, specifically no neurological abnormality. He was prescribed back-to-back Salbutamol nebulisers, to increase the shift of extracellular potassium into the intracellular space, followed by i.v. calcium gluconate, with some improvement in potassium levels. A further 5 mmol of sodium bicarbonate was given, as well as a stat dose of 1 mg/kg furosemide, and per rectal calcium resonium. He was then commenced on an infusion with 10% dextrose with insulin. He was subsequently found to be in urinary retention and a catheter was inserted, which drained 1700 ml. A subsequent renal function profile, 24 hours after admission, demonstrated improvement with urea 39 mmol l−1, creatinine 300 micromol/L and potassium 3.0 mEq/L.
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Affiliation(s)
- Amar Ajay Chotai
- Department of Neuroradiology, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
| | - Dipayan Mitra
- Department of Neuroradiology, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
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28
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Lyerly MJ, Chow D. Neuroimaging Considerations in Patients with Chronic Kidney Disease. J Stroke Cerebrovasc Dis 2021; 30:105930. [PMID: 34176719 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic Kidney Disease is a common medical condition that frequently overlaps with neurologic disease. Neuroimaging can be a useful tool to aid in the diagnoses of neurologic illness, including those that result from renal impairment. Some neuroimaging studies also have the potential to lead to adverse effects on the kidneys necessitating a thoughtful approach to selection of imaging modalities. In particular, multimodal imaging is becoming increasingly common in patients presenting with symptoms of acute stroke, a population that may be at higher risk for renal complications. This article will summarize the neuroimaging manifestations of conditions with shared renal and neurologic involvement and highlight considerations regarding the use of contrast media, nephrogenic systemic fibrosis, and metformin-associated lactic acidosis.
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Affiliation(s)
- Michael J Lyerly
- Department of Neurology, University of Alabama at Birmingham USA; Birmingham VA Medical Center USA.
| | - Daniel Chow
- Department of Radiology, University of California-Irvine USA
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29
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Sanchez-Meza F, Torre A, Castillo-Martinez L, Sanchez-Roman S, Morales-Buenrostro LE. Evaluation of cerebral dysfunction in patients with chronic kidney disease using neuropsychometric and neurophysiological tests. Ren Fail 2021; 43:577-584. [PMID: 33757399 PMCID: PMC7993379 DOI: 10.1080/0886022x.2021.1901740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Uremic encephalopathy is defined as cerebral dysfunction due to toxin accumulation in patients with chronic kidney disease (CKD). This condition is characterized by subtle to florid symptoms, and its clinical course is always progressive when untreated but partially reversible with renal replacement therapy. While no test exists to measure subclinical uremic encephalopathy, two tests have been validated to measure minimal hepatic encephalopathy: the critical flicker frequency (CFF) test and the psychometric hepatic encephalopathy score (PHES). Objective To use CFF and PHES to measure the prevalence of cerebral dysfunction in individuals with CKD. Methods This cross-sectional study included a total of 69 patients with stage-5 CKD. Cutoff points for minimal encephalopathy were established using existing clinical guidelines: ≤39 Hz for CFF and < −4 for PHES. All participants were also screened for cognitive function and depression. Results Eighteen cases (26.1%) of cerebral dysfunction linked to uremic encephalopathy were detected with CFF, while twelve (17.4%) were detected by PHES; only six cases (8.7%) were diagnosed by both methods. Half of the cases (50%) had diabetes, and 61% were on hemodialysis. Cognitive function scores did not differ significantly between those receiving dialysis, hemodialysis, or no renal replacement therapy. Conclusions It is essential to identify cerebral dysfunction when uremic encephalopathy is in early subclinical stages to reduce preventable events as traffic and work accidents.
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Affiliation(s)
- Fabiola Sanchez-Meza
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico
| | - Aldo Torre
- Liver Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico
| | - Lilia Castillo-Martinez
- Department of Clinical Nutrition, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico
| | - Sofia Sanchez-Roman
- Neurology and Psychiatry Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico
| | - Luis Eduardo Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico
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30
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Ishii N, Sakai K, Mochizuki H, Shiomi K. Reversible Parkinsonism Due to Diabetic Uremic Syndrome. Intern Med 2020; 59:3251-3252. [PMID: 32759594 PMCID: PMC7807099 DOI: 10.2169/internalmedicine.5355-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nobuyuki Ishii
- Department of Neurology, University of Miyazaki Hospital, Japan
- Department of Neurology, Chiyoda Hospital, Japan
| | - Katsuya Sakai
- Department of Neurology, University of Miyazaki Hospital, Japan
| | | | - Kazutaka Shiomi
- Department of Neurology, University of Miyazaki Hospital, Japan
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31
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Burek M, Burmester S, Salvador E, Möller-Ehrlich K, Schneider R, Roewer N, Nagai M, Förster CY. Kidney Ischemia/Reperfusion Injury Induces Changes in the Drug Transporter Expression at the Blood-Brain Barrier in vivo and in vitro. Front Physiol 2020; 11:569881. [PMID: 33281613 PMCID: PMC7688901 DOI: 10.3389/fphys.2020.569881] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/20/2020] [Indexed: 01/25/2023] Open
Abstract
Ischemia/reperfusion injury is a major cause of acute kidney injury (AKI). AKI is characterized by a sudden decrease in kidney function, systemic inflammation, oxidative stress, and dysregulation of the sodium, potassium, and water channels. While AKI leads to uremic encephalopathy, epidemiological studies have shown that AKI is associated with a subsequent risk for developing stroke and dementia. To get more insights into kidney-brain crosstalk, we have created an in vitro co-culture model based on human kidney cells of the proximal tubule (HK-2) and brain microvascular endothelial cells (BMEC). The HK-2 cell line was grown to confluence on 6-well plates and exposed to oxygen/glucose deprivation (OGD) for 4 h. Control HK-2 cells were grown under normal conditions. The BMEC cell line cerebED was grown to confluence on transwells with 0.4 μm pores. The transwell filters seeded and grown to confluence with cereEND were inserted into the plates with HK-2 cells with or without OGD treatment. In addition, cerebEND were left untreated or treated with uremic toxins, indole-3-acetic acid (IAA) and indoxyl sulfate (IS). The protein and mRNA expression of selected BBB-typical influx transporters, efflux transporters, cellular receptors, and tight junction proteins was measured in BMECs. To validate this in vitro model of kidney-brain interaction, we isolated brain capillaries from mice exposed to bilateral renal ischemia (30 min)/reperfusion injury (24 h) and measured mRNA and protein expression as described above. Both in vitro and in vivo systems showed similar changes in the expression of drug transporters, cellular receptors, and tight junction proteins. Efflux pumps, in particular Abcb1b, Abcc1, and Abcg2, have shown increased expression in our model. Thus, our in vitro co-culture system can be used to study the cellular mechanism of kidney and brain crosstalk in renal ischemia/reperfusion injury.
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Affiliation(s)
- Malgorzata Burek
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Sandra Burmester
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Ellaine Salvador
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Kerstin Möller-Ehrlich
- Division of Nephrology, Department of Medicine I, University of Würzburg, Würzburg, Germany
| | - Reinhard Schneider
- Division of Nephrology, Department of Medicine I, University of Würzburg, Würzburg, Germany
| | - Norbert Roewer
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Carola Y. Förster
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
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32
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2020; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/01/2023] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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33
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Van Cauter S, Severino M, Ammendola R, Van Berkel B, Vavro H, van den Hauwe L, Rumboldt Z. Bilateral lesions of the basal ganglia and thalami (central grey matter)-pictorial review. Neuroradiology 2020; 62:1565-1605. [PMID: 32761278 PMCID: PMC7405775 DOI: 10.1007/s00234-020-02511-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
The basal ganglia and thalami are paired deep grey matter structures with extensive metabolic activity that renders them susceptible to injury by various diseases. Most pathological processes lead to bilateral lesions, which may be symmetric or asymmetric, frequently showing characteristic patterns on imaging studies. In this comprehensive pictorial review, the most common and/or typical genetic, acquired metabolic/toxic, infectious, inflammatory, vascular and neoplastic pathologies affecting the central grey matter are subdivided according to the preferential location of the lesions: in the basal ganglia, in the thalami or both. The characteristic imaging findings are described with emphasis on the differential diagnosis and clinical context.
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Affiliation(s)
- Sofie Van Cauter
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium. .,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium.
| | - Mariasavina Severino
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Rosamaria Ammendola
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Brecht Van Berkel
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium
| | - Hrvoje Vavro
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, Croatia
| | - Luc van den Hauwe
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.,Department of Medical Imaging, AZ KLINA, Augustijnslei 100, 2930, Brasschaat, Belgium
| | - Zoran Rumboldt
- Department of Radiology, University of Rijeka School of Medicine, Ulica Braće Branchetta 20, 51000, Rijeka, Croatia.,Department of Radiology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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Koksel Y, McKinney A. Potentially Reversible and Recognizable Acute Encephalopathic Syndromes: Disease Categorization and MRI Appearances. AJNR Am J Neuroradiol 2020; 41:1328-1338. [PMID: 32616580 PMCID: PMC7658879 DOI: 10.3174/ajnr.a6634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/26/2020] [Indexed: 01/21/2023]
Abstract
"Encephalopathy" is a vague term that encompasses varying definitions, often with a nonspecific clinical presentation and numerous possible pathophysiologic causes. Hence, MR imaging plays a crucial role in the early diagnosis and treatment by identifying imaging patterns when there is limited clinical history in such patients with acute encephalopathy. The aim of this review was to aid in remembrance of etiologies of potentially reversible acute encephalopathic syndromes on MR imaging. The differential includes vascular (reversible cerebral vasoconstriction syndrome, transient global amnesia, disseminated intravascular coagulation, and thrombotic microangiopathy), infection (meningitis, encephalitis), toxic (posterior reversible encephalopathy syndrome, acute toxic leukoencephalopathy; carbon monoxide, alcohol-related, medication- and illicit drug-related toxic encephalopathies), autoimmune, metabolic (osmotic demyelination syndrome, uremic, acute hepatic encephalopathy), idiopathic/inflammatory (stroke-like migraine attacks after radiation therapy syndrome), neoplasm-related encephalopathy, and seizure-related encephalopathy.
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Affiliation(s)
- Y. Koksel
- From the Department of Radiology (Y.K.), Division of Neuroradiology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - A.M. McKinney
- Department of Radiology (A.M.M.), University of Miami School of Medicine, Miami, Florida
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35
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O'Dowd S, Schumacher J, Burn DJ, Bonanni L, Onofrj M, Thomas A, Taylor JP. Fluctuating cognition in the Lewy body dementias. Brain 2020; 142:3338-3350. [PMID: 31411317 DOI: 10.1093/brain/awz235] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/28/2019] [Accepted: 06/09/2019] [Indexed: 01/17/2023] Open
Abstract
Fluctuating cognition is a core diagnostic feature of dementia with Lewy bodies and is also a key clinical feature of Parkinson's disease dementia. These dementias share common pathological features and are referred to as Lewy body dementias. Whilst highly prevalent in Lewy body dementia, with up to 90% of patients experiencing the symptom at some point in the disease trajectory, clinical identification of fluctuating cognition is often challenging. Furthermore, its underlying pathophysiological processes remain unclear. However, neuroimaging and neurophysiological techniques have recently provided insight into potential drivers of the phenomenon. In this update, we review data pertaining to clinical features and underlying mechanisms of fluctuating cognition in Lewy body dementia. We collate evidence for different proposed aetiologies: fluctuating cognition as an attentional disorder, as a consequence of loss of cholinergic drive, as a manifestation of failure in neuronal efficiency and synchrony, and as a disorder of sleep/arousal. We also review data relating to putative mechanisms that have received less attention to date. Increased understanding of fluctuating cognition may help to illuminate pathophysiological mechanisms in cognitive processing in Lewy body dementia, guide future research, and facilitate the design of targeted therapeutic approaches.
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Affiliation(s)
- Seán O'Dowd
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK.,Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland; Academic Unit of Neurology, Trinity College Dublin, Ireland
| | - Julia Schumacher
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - David J Burn
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Science and Aging Research Centre, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Science and Aging Research Centre, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Alan Thomas
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - John-Paul Taylor
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
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Jaryal A, Thakur S, Pathania JS, Vikrant S, Kumar D, Verma L. Lentiform fork sign: Uremia alone or multifactorial causation? Hemodial Int 2019; 24:E10-E12. [PMID: 31840926 DOI: 10.1111/hdi.12810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 11/28/2022]
Abstract
Neurological complications are common in patients with acute or chronic renal failure, especially when there is marked reduction in the glomerular filtration rate (GFR). One such clinical syndrome, uremic encephalopathy (UE), occurs due to widespread dysfunction of central nervous system (CNS). It manifests with myriad clinical features and usually is suggested by bedside elicitation of asterixis (flapping tremor). Symptomatic involvement of the basal ganglia manifesting as choreoathetosis and clinical and radiological resolution with hemodialysis has been reported in the medical literature, but only rarely. The present report details such a case.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Suresh Thakur
- Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, India
| | | | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Dinesh Kumar
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
| | - Lokesh Verma
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
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Cirillo G, Cirillo M, Panetsos F, Virtuoso A, Papa M. Selective Vulnerability of Basal Ganglia: Insights into the Mechanisms of Bilateral Striatal Necrosis. J Neuropathol Exp Neurol 2019; 78:123-129. [PMID: 30605553 DOI: 10.1093/jnen/nly123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Selective neuronal death in neurodegenerative disorders represents the final step of a cascade of events, including neuroinflammation, regional-specific reactive gliosis, changes of brain-blood barrier structure and functions, metabolic failure and mitochondrial energy impairment. Bilateral striatal necrosis is usually reported in inherited mitochondrial disorders, suggesting a pathogenetic role of the energy impairment by mitochondrial dysfunction. We investigated mechanisms of the selective striatal degeneration, comparing clinical findings of a patient with an acquired bilateral striatal necrosis and experimental data of a selective basal ganglia degenerative model in rats. In a 70-year-old patient affected by severe parkinsonian syndrome triggered by persistent metabolic acidosis, brain MRI revealed bilateral cystic-lacunar necrosis of basal ganglia. Immunohistochemistry of rat brain sections after single intraperitoneal administration (60 mg/kg) of the mitochondrial toxin 3-nitropropionic acid (3-NP) revealed (i) selective bilateral striatal necrotic/cavitary lesions, (ii) degeneration of striatal medium spiny neurons, (iii) evidence of synaptic and transcriptional dysfunction, and (iv) reactive gliosis (activated microglia and astrocytes) in the striatum. Our data provide an intriguing hypothesis for the selective neuronal degeneration in the striatum, claiming that selective mitochondrial energy impairment associated to loco-regional neuroinflammation and reactive gliosis might contribute to synaptic dysfunction and excitotoxicity that ultimately lead to neuronal degeneration.
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Affiliation(s)
- Giovanni Cirillo
- Division of Human Anatomy - Neuronal Networks Morphology Lab, Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli"
| | - Mario Cirillo
- Division of Human Anatomy - Neuronal Networks Morphology Lab, Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli".,Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fivos Panetsos
- Division of Human Anatomy - Neuronal Networks Morphology Lab, Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli".,Neuro-computing & Neuro-robotics Research Group, Universidad Complutense de Madrid.,Neural Plasticity Research Group, Instituto Investigación Sanitaria Hospital Clínico San Carlos, Madrid, Spain
| | - Assunta Virtuoso
- Division of Human Anatomy - Neuronal Networks Morphology Lab, Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli"
| | - Michele Papa
- Division of Human Anatomy - Neuronal Networks Morphology Lab, Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli"
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de Oliveira AM, Paulino MV, Vieira APF, McKinney AM, da Rocha AJ, dos Santos GT, Leite CDC, Godoy LFDS, Lucato LT. Imaging Patterns of Toxic and Metabolic Brain Disorders. Radiographics 2019; 39:1672-1695. [DOI: 10.1148/rg.2019190016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sarbu MI, Sarbu N. Central PRES (posterior reversible encephalopathy syndrome) in HELLP syndrome. Intern Emerg Med 2019; 14:617-618. [PMID: 30519918 DOI: 10.1007/s11739-018-2003-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Mihaela Ionela Sarbu
- Department of Rheumatology, "Saint Pierre" University Hospital, and Erasme Hospital, Brussels, Belgium
| | - Nicolae Sarbu
- Department of Neuroradiology, Erasme Hospital, University of Brussels (ULB), Route de Lennik 808, 1070, Brussels, Belgium.
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Yang L, Gong NR, Zhang Q, Ma YB, Zhou H. Apparent Correlations Between AMPK Expression and Brain Inflammatory Response and Neurological Function Factors in Rats with Chronic Renal Failure. J Mol Neurosci 2019; 68:204-213. [PMID: 30919248 DOI: 10.1007/s12031-019-01299-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023]
Abstract
To explore the correlations between AMP-activated protein kinase (AMPK) expression and brain inflammatory response and neurological function factors in rats with chronic renal failure. Chronic renal failure models in rats were established, and the healthy control group (normal group) was set. Chronic renal failure model rats were divided into model group (without any treatment), control group (intraperitoneal injection of normal saline), A-769662 group (intraperitoneal injection of AMPK specific activator), and compound C group (intraperitoneal injection of AMPK specific inhibitor). The results of HE staining showed renal tissue enlargement, and significant pathological changes. Compared with the normal group, AMPK level in peripheral blood and AMPK mRNA and protein expressions in brain tissue were significantly reduced, and AMPK pathway activation was significantly inhibited in other groups. Compared with the model group, rats in the A-769662 group had significantly decreased serum creatinine (Scr) and blood urea nitrogen (BUN) levels and γ-aminobutyric acid (γ-GABA) content, significantly increased brain-derived neurotrophic factor (BDNF) positive expressions and 5-hydroxytryptamine (5-HT) content, and decreased interleukin-1 (IL-1), tumor necrosis factor-α (TNF-α), and intercellular adhesion molecule 1 (ICAM-1) expressions (all P < 0.05), while it was just the opposite in compound C group (all P < 0.05). There is an apparent correlation between AMPK expression and brain inflammatory response in chronic renal failure rats. AMPK is expected to be an important pathway in the treatment of uremic encephalopathy.
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Affiliation(s)
- Li Yang
- Department of Nephrology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, Guangdong Province, China
| | - Ni-Rong Gong
- Department of Nephrology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, Guangdong Province, China
| | - Qin Zhang
- Department of Nephrology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, Guangdong Province, China
| | - Ya-Bin Ma
- Department of Neurosurgery, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglin Xia Road, Yuexiu District, Guangzhou, 510080, Guangdong Province, China
| | - Hui Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglin Xia Road, Yuexiu District, Guangzhou, 510080, Guangdong Province, China.
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Kang J, Kwon H, Jung CK, Bae HJ, Han MK, Kim BJ, Jo YH. Usefulness of hyperintense acute reperfusion marker sign in patients with transient neurologic symptom. Medicine (Baltimore) 2019; 98:e15494. [PMID: 31083188 PMCID: PMC6531152 DOI: 10.1097/md.0000000000015494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
It aimed to investigate the incidence and final diagnosis of hyperintense acute reperfusion marker (HARM) signs in patients initially suspected of having a transient ischemic attack (TIA).In retrospective manner, a series of consecutive series of patients who arrived at the emergency department and was initially assessed as TIA within 12 hours of symptom onset between July 2015 and December 2016 were enrolled. Conventional magnetic resonance imaging protocol including diffusion-weighted imaging (DWI) and pre- and post-contrast fluid attenuation inversion recovery imaging (FLAIR) was conducted to evaluate the ischemic lesion and prognosis. Through the review of medical records and imaging studies, their final diagnosis and its association with HARM signs on post-contrast FLAIR were investigated.A total of 174 subjects were enrolled (mean age, 64.0 ± 12.9 years old; male, 54.6%; DWI lesion, 17.8%). HARM signs were observed in 18 (10%) patients, and their final diagnoses were classified as true TIA (n = 11, 61%), seizure (2, 11%), posterior reversible encephalopathy (2, 11%), reversible cerebral vascular constriction (1, 6%) and unclassified encephalopathy (2, 11%). The co-occurrence of HARM and DWI lesions were observed in 7 subjects which were 6 subjects of true TIA (ischemic stroke) and 1 subject with RCVS related ischemic stroke.The observation of HARM sign would be helpful to confirm the ischemic insult and distinguish the other disease.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do
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Bilateral thalamic and basal ganglia lesions in an old woman: unusual involvement of uremic encephalopathy. Acta Neurol Belg 2019; 119:133-135. [PMID: 30196371 DOI: 10.1007/s13760-018-1020-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
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Özütemiz C, Roshan SK, Kroll NJ, Benson JC, Rykken JB, Oswood MC, Zhang L, McKinney AM. Acute Toxic Leukoencephalopathy: Etiologies, Imaging Findings, and Outcomes in 101 Patients. AJNR Am J Neuroradiol 2019; 40:267-275. [PMID: 30679224 DOI: 10.3174/ajnr.a5947] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/03/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prior studies regarding acute toxic leukoencephalopathy (ATL) are either small, or preliminary. Our aim was to evaluate etiologies of and differences in imaging severity and outcomes among various etiologies of ATL. MATERIALS AND METHODS MRIs of patients with suspected ATL over 15 years were retrospectively reviewed; inclusion criteria were: MRI <3 weeks of presentation with both DWI and FLAIR. These were jointly graded by two neuroradiologists via a previously described score of severity. Clinical outcome was evaluated via both modified Rankin (mRS) and ATL outcome (ATLOS) scores, each being correlated with the DWI and FLAIR scores. Etiologic subgroups of n > 6 patients were statistically compared. RESULTS Of 101 included patients, the 4 subgroups of n > 6 were the following: chemotherapy (n = 35), opiates (n = 19), acute hepatic encephalopathy (n = 14), and immunosuppressants (n = 11). Other causes (n = 22 total) notably included carbon monoxide (n = 3) metronidazole (n = 2), and uremia (n = 1). The mean DWI/FLAIR severity scores were 2.6/2.3, 3.3/3.3, 2.1/2.1 and 2.0/2.5 for chemotherapeutics, opiates, AHE and immunosuppressants, respectively, with significant differences in both imaging severity and outcome (P = .003-.032) among subgroups, particularly immunosuppressant versus chemotherapy-related ATL and immunosuppressants versus opiates (P = .004-.032) related ATL. DWI and FLAIR severity weakly correlated with outcome (ρ = 0.289-.349, P < .005) but correlated stronger in the chemotherapy (ρ = 0.460-.586, P < .010) and opiate (ρ =.472-.608, P < .05) subgroups, which had the worst outcomes. ATL clinically resolved in 36%, with severe outcomes in 23% (coma or death, 9/16 deaths from fludarabine). Notable laboratory results were elevated CSF myelin basic protein levels in 8/9 patients and serum blood urea nitrogen levels in 24/91. CONCLUSIONS Clinical outcomes of ATL vary on the basis of etiology, being worse in chemotherapeutic- and opiate-related ATL. Uremia may be a predisposing or exacerbating factor.
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Affiliation(s)
- C Özütemiz
- From the Department of Radiology (C.Ö., S.K.R., J.C.B., J.B.R., A.M.M.)
| | - S K Roshan
- From the Department of Radiology (C.Ö., S.K.R., J.C.B., J.B.R., A.M.M.)
| | - N J Kroll
- Faculty of Medicine (N.J.K.), University of Minnesota, Minneapolis, Minnesota
| | - J C Benson
- From the Department of Radiology (C.Ö., S.K.R., J.C.B., J.B.R., A.M.M.)
| | - J B Rykken
- From the Department of Radiology (C.Ö., S.K.R., J.C.B., J.B.R., A.M.M.)
| | - M C Oswood
- Department of Radiology (M.C.O.), Hennepin County Medical Center, Minneapolis, Minnesota
| | - L Zhang
- Biostatistics Design and Analysis Center (L.Z.), Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology (C.Ö., S.K.R., J.C.B., J.B.R., A.M.M.)
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44
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Hsu CCT, Krings T. Acquired Metabolic Diseases. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_69-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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45
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Acquired Metabolic Diseases. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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46
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Jung JH. Bilateral Basal Ganglia Lesions in a Dialytic Patient with Diabetes and Recurrent Hypoglycemia. Chonnam Med J 2019; 55:173-174. [PMID: 31598478 PMCID: PMC6769242 DOI: 10.4068/cmj.2019.55.3.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/06/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jong Hwan Jung
- Division of Nephrology, Department of Internal Medicine, Wonkwang University School of Medicine and Hospital, Iksan, Korea
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47
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Gong WY, Li SS, Yu ZC, Wu HW, Yin LH, Mei LF, Liu FN. Syndrome of uremic encephalopathy and bilateral basal ganglia lesions in non-diabetic hemodialysis patient: a case report. BMC Nephrol 2018; 19:370. [PMID: 30567505 PMCID: PMC6299987 DOI: 10.1186/s12882-018-1174-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uremic encephalopathy (UE), a toxic metabolic encephalopathy, is an uncommon complication resulting from endogenous uremic toxins in patients with severe renal failure. UE syndrome can range from mild inattention to coma. The imaging findings of UE include cortical or subcortical involvement, basal ganglia involvement and white matter involvement. The basal ganglia type is uncommon, although previous cases have reported that Asian patients with diabetes mellitus (DM) are usually affected. CASE PRESENTATION A 32 year-old woman with a history of non-diabetic hemodialysis for 3 years suffered from severe involuntary movement, and brain magnetic resonance imaging showed symmetrical T2-weighted imaging (T2WI) and T2/fluid-attenuated inversion recovery (T2FLAIR) hyperintense nonhemorrhagic lesions in the bilateral basal ganglia. She was diagnosed with UE as syndrome of bilateral basal ganglia lesions, due to a combined effect of uremic toxins and hyperthyroidism. After treatment with high frequency and high flux dialysis, hyperbaric oxygen therapy and declining parathyroid hormone, the patient achieved complete remission with normal body movement and was discharged. CONCLUSION UE with basal ganglia involvement is uncommon, although generally seen in Asian patients with DM. Our case reported a hemodialysis patient that had non-diabetic UE with typical bilateral basal ganglia lesions, presenting with involuntary movement.
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Affiliation(s)
- Wen-Yu Gong
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Shan-Shan Li
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Zong-Chao Yu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Hong-Wei Wu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Liang-Hong Yin
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Li-Fan Mei
- Division of Nephrology, Department of medicine, Zhongshan Boai Hospital, Zhongshan, 528400, Guangdong, China
| | - Fan-Na Liu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China.
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Koksel Y, Benson J, Huang H, Gencturk M, McKinney AM. Review of diffuse cortical injury on diffusion-weighted imaging in acutely encephalopathic patients with an acronym: "CRUMPLED". Eur J Radiol Open 2018; 5:194-201. [PMID: 30456218 PMCID: PMC6231053 DOI: 10.1016/j.ejro.2018.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Acute encephalopathic syndromes can present a diagnostic challenge due to the wide range of possible etiologies, which also can have vastly different outcomes. The presence of diffuse cortical injury (DCI) on diffusion-weighted imaging (DWI) can help narrow the differential diagnosis. The aim of this review is to categorize the range of possible etiologies of DCI into a useful acronym, "CRUMPLED". Methods A review of the PACS system was completed to find a characteristic example of patients with DCI on DWI from different etiologies. The diagnosis was confirmed for each example via a subsequent review of the electronic medical record used to assess for data such as biopsy results, laboratory values, and clinical correlation. The electronic exhibit intends to demonstrate several sample cases of each letter within the acronym, and to demonstrate which types of DCI are potentially reversible or irreversible. Findings/Discussion The possible etiologies of DCI on DWI can be organized using the acronym "CRUMPLED": 'C' = Creutzfeldt-jakob disease, 'R' = reversible cerebral vasoconstriction syndrome; 'U' = urea cycle disorders (hyperammonemia) and Uremia; 'M' = mitochondrial (cytopathy/encephalopathy); 'P' = prolonged seizure and posterior reversible encephalopathy (PRES); 'L' = laminar necrosis (hypoxic-ischemic encephalopathy) and liver disease (acute hepatic encephalopathy); 'E' = encephalitis (infectious meningoencephalitis); 'D' = diabetes mellitus (hypoglycemia). Other secondary imaging findings (outside of DWI) can be used to help differentiate between the aforementioned etiologies, such as the use of ADC maps, FLAIR imaging, intravenous contrast. Conclusion "CRUMPLED" is proposed as a convenient acronym for the categorization of a diverse range of acute etiologies associated with DCI on DWI, arising from varying degrees of cytotoxic edema. These etiologies can range from being potentially reversible (e.g. hyperammonemia or prolonged seizures) to irreversible (e.g. hypoxic-ischemic injury).
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Key Words
- AHE, Acute Hepatic/Hyperammonemic Encephalopathy
- Acute encephalopathy
- CJD, Creutzfeldt-Jakob disease
- DCI, Diffuse cortical injury
- DWI
- Diffuse cortical injury
- MELAS, mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes
- PRES, Posterior reversible encephalopathy syndrome
- RCVS, Reversible cerebral vasoconstriction syndrome
- UCD, Urea cycle disorders
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Affiliation(s)
- Yasemin Koksel
- Corresponding author at: Dept. of Radiology, Mayo Building, Univ. of MN, 420 Delaware St. SE, 55418, USA.
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Godinho MV, Pires CE, Hygino da Cruz LC. Hypoxic, Toxic, and Acquired Metabolic Encephalopathies at the Emergency Room: The Role of Magnetic Resonance Imaging. Semin Ultrasound CT MR 2018; 39:481-494. [DOI: 10.1053/j.sult.2018.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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Advances in dialysis encephalopathy research: a review. Neurol Sci 2018; 39:1151-1159. [PMID: 29721635 DOI: 10.1007/s10072-018-3426-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
Dialysis encephalopathy (DE) is a progressive, fatal disease with a high mortality rate. Understanding the causes of this disease and the efforts to prevent and treat it would help improve the prognosis and quality of life of affected patients. This paper reviews the etiology, clinical features, methods of examining accessory features, diagnosis, treatment, and prevention of DE. We found that DE is likely to be related to aluminum poisoning. The clinical manifestations of DE include language disorders, mental and behavioral disorders, cognitive decline, and movement disorders. Electroencephalogram (EEG) findings mainly consist of an abundance of low waves, intermittent bilateral synchronous high-amplitude spikes, and ridge waves. Assessing the clinical features and obtaining an EEG are of great value in diagnosis, and DE is treated by both reducing aluminum intake and increasing aluminum excretion. Deferoxamine (DFO) is an effective treatment for DE.
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